(Hardcopy/paper) - WCC Form C1-Rev 3/98
IMPORTANT: It is the Claimant's responsibility to maintain a current mailing address with the Commission. The Commission Claim Number should be included on all correspondence.
Disclosure Pursuant to COMAR 01.01.1983.18
The personal information requested on this form is intended to be used in processing your claim under the Maryland workers' compensation laws.
Failure to provide the information requested may result in your claim being rejected or a delay in the processing of your claim.
You may have a right to inspect, amend and correct the information provided on this form pursuant to State Government Article, 10-624, Maryland Code Annotated.
This form will be made part of your claim file. Portions of your claim file may be subject to public inspection.
The information contained on this form is routinely shared with State, Federal or local agencies.
Claim Filing Instructions
ONLY an ORIGINAL claim form
obtained from the Workers' Compensation Commission will be
This form may not be submitted as a photocopy or recreated on office systems.
Such recreated forms will be returned to the sender without processing the claim.
The Commission does not accept any claim forms, documents or claim-related information via facsimile (FAX) or email
(electronic mail) or attachment.
HANDWRITTEN EXAMPLE - ONE LETTER PER BOX
TYPED EXAMPLE- START AT LEFT BOX EDGE, DO NOT EXCEED RIGHT BOX EDGE
All entries MUST be hand written in UPPER CASE letters or typed. If hand written, print as clearly as possible in DARK OR BLACK INK using only capital (upper case) letters, one letter per box.
Provide the requested information in each numbered section. Leave at least one blank box/space between each word for any entry.
Dates must be filled in MMDDYYYY (month-day-year) format. "Leading zeros" must be entered with single digit numbers, e.g. January 5, 1999 must be entered as 01051999.
Dollar values must be entered with no dollar sign or
decimal point, e.g. Gross Wages: $112.15 is entered as
When information is unknown or not
available, zeros MUST be entered. For example, Social
Security Number: 000000000 (9 zeros). Gross Wages should
be entered with no dollar sign or decimal point. For
example, $112.51 is entered as 11215, or if unknown or
not available, all zeros.
Entries MUST NOT exceed the length of the indicated field (boxes). If the information is longer than the field allows, please abbreviate WITHOUT punctuation. Ensure that ALL entries are within the boundaries of the boxes (fields) on the form.
Typed responses must stay within the confines of the box/answer field. The Workers' Compensation Commission uses a computerized character/letter recognition system. Caution should be used with all letters than may be misrepresented by the computer, such as V and U, L and I, etc.
DO NOT use letters in boxes requiring such information as telephone number or Social Security number.
WHEN THERE IS NOT ENOUGH SPACE ON THE CLAIM FORM FOR INFORMATION, PLEASE ATTACH ADDITIONAL PAGES WITH A PAPER CLIP. PLEASE NUMBER THE ITEMS THAT ARE BEING ADDED, e.g. #15.
DO NOT cross out, staple, tape or use correction fluid or tape (White-Out) on the form.
A claim form that does not contain the claimant's name, address, date of accident or occupational disease, date of birth, the member of the body that was injured, a description of how the accidental injury or occupational disease occurred, or sufficient information to process the claim may be rejected and returned to the claimant.
Sign and date the claim information section of the form. Read, sign and date the Authorization for Disclosure of Health Information section of the form. Mail the completed form to the Commission at the address below.
A claim form that does not include the signed Authorization for Disclosure of Health Information will be rejected and returned to the claimant.
When your claim has been processed, we will mail a "Notice of Claim" to all parties in the claim (claimant, employer/insurer and/or their legal representatives).
FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN UNNECESSARY DELAY OR RETURN FOR CORRECTION AND RESUBMISSION OF THE CLAIM FORM.
WCC COUNTY CODES TO COMPLETE THE CLAIM FORM
Allegany - AL
Charles - CH
Prince George's - PG
Anne Arundel - AA
Dorchester - DR
Queen Anne's - QA
Baltimore - BA
Frederick - FR
Saint Mary's - SM
Baltimore City - BC
Garrett - GA
Somerset - SO
Calvert - CT
Harford - HA
Talbot - TA
Caroline - CA
Howard - HO
Washington - WA
Carroll - CL
Kent - KT
Wicomico - WI
Cecil - CE
Montgomery - MT
Worcester - WO
Out of State (outside Maryland) - OS
To request additional information or forms
|Our Mailing Address:
Maryland Workers' Compensation Commission
10 East Baltimore Street
Baltimore, Maryland 21202-1641
(click on the link below, state that you need a Claim Form and provide your shipping address, this form is not email-able):
|Via telephone:(410) 864-5100
(800) 492-0479 (Outside Metro Baltimore)
Maryland Relay for hearing impaired dial 711
Copyright @COPY; 2009